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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002504
Report Date: 10/19/2023
Date Signed: 10/19/2023 01:41:09 PM

Document Has Been Signed on 10/19/2023 01:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NELSON HOMEFACILITY NUMBER:
045002504
ADMINISTRATOR:STEVEN CONNORSFACILITY TYPE:
735
ADDRESS:77 NELSON AVENUETELEPHONE:
(530) 353-3111
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 6CENSUS: 6DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Maria Ruiz - Care staffTIME COMPLETED:
01:45 PM
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10/18/2023 11:40 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with care staff Maria Ruiz and explained the purpose of the visit. Administrator Nora Serrano was unavailable during the visit and gave Ms. Ruiz permission to conduct visit with LPA.

LPA Knight and Ms. Ruiz toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to six (6)) client rooms, common areas, three (3) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. All employees requiring background checks are cleared.

Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a cabinet.

The facility was observed to be at a comfortable temperature. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and were inspected in December 2022. Smoke detectors are all operational. No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted in June 2023 which was a fire drill.

The following deficiencies are being cited as a result of today’s inspection and are documented on the attached LIC809-D. LPA observed cracked tiles in the staff bedroom and outside in the hallway that prevents the staff door from opening completely. LPA observed laminate flooring to be taped down in patches and needs to be repaired in clients room and common areas. LPA observed the exterior paint of the facility to be worn and peeling.

Exit interview conducted and copy of report was provided to administrator Nora Serrano.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2023 01:41 PM - It Cannot Be Edited


Created By: Rebecca Knight On 10/19/2023 at 01:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NELSON HOME
FACILITY NUMBER: 045002504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the licensee did not comply with the section cited above. LPA observed cracked tiles in the staff bedroom and outside in the hallway that prevents the staff door from opening completely LPA observed laminate flooring to be taped down in patches and needs to be repaired in clients room and common areas. LPA observed the exterior paint of the facility to be worn and peeling which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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Licensee shall submit a plan with dates of start and completion of work to LPA as proof of correction. Licensee agrees to submit photographs of the completed work to LPA when the work has been completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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